What you need to know as a new parent of a premature or low-weight baby before driving home from hospital:

Premature babies in cars are not always safe & driving with low-weight or premature babies is risky.

The mother of a baby who began foaming at the mouth after a two-hour car journey warned other parents to avoid leaving their babies in their car seats, after her terrifying experience of arriving home to discover her 3-week-old baby daughter had developed blue lips from cyanosis brought on during the journey home.


Research warning

Carrying children in child seats for long periods of time has been well documented as dangerous. However, newer studies specifically highlight the dangers for premature or low-birth-weight children. Furthermore, it illustrates the need for extra care when selecting correct equipment for transporting a newborn in a vehicle.


Safety advice

It is such an important topic that RoSPA the Royal Society for the Prevention of Accidents recently issued safety advice on the matter.


Simulator study

A study by the Lullaby Trust in 2016 assessed 40 full term and pre-term infants using a simulator. They found that when placed in their car seats a 40 degree position and simulating the vibration that an infant would typically experience in a moving vehicle, both term and preterm infants reported significantly faster heartbeats, lower oxygen saturation and higher respiratory rates.


The conclusion from this study was that further studies should be undertaken as a matter of urgency.

To date we have been unable to find any further studies since 2016.


How taking the car seat challenge could save lives

The American Association of Paediatrics recommends that all pre-term infants undergo a ‘car seat challenge’ (which assesses whether pre-term infants who are ready for discharge home are prone to episodes of apnoea (stopping breathing), bradycardia (slow heart rate), or desaturation (low oxygen levels) when seated in their car seat) to ensure that the infant is safe to travel.

Most UK neonatal units also test babies in this way before they are discharged home from hospital.


What is a low-weight baby?

A low weight baby is one born weighing less than five and a half pounds or 2499 grams.


What is a premature baby?

A baby is considered premature if it is born before 37 weeks.


Why is this more of an issue now?

The issue is more pressing than ever due to the is coming to the improved survival rates of premature babies as well as because premature babies are discharged from hospital earlier.


Rear-facing child seat

These are the most common parental choice of seat for infants.


The problem

The typical rear-facing car seats position the baby at an angle between 40 and 45 degrees.

However, with small babies, because of the shape of their head and nature of their airway, it is possible that the angle of the car seat could result in their head falling forward restricting their airway and making it difficult for them to breathe.

However, studies looking at lie flat carriers and rear facing car seats have both shown that babies experience reduced oxygenation when travelling and so this does not appear to be the full story and more investigation is needed.


Further medical considerations

Additionally, risks for smaller babies are higher for the following medical problems:

  1. hypotonia – decreased muscle tone known as floppy baby syndrome
  2. oxygen desaturation – low oxygen levels i.e. the percentage of oxygen-saturated haemoglobin in relation to the total amount of haemoglobin in the blood
  3. apnoea – temporarily stopping breathing, particularly whilst asleep
  4. bradycardia – abnormally low heart rate



Lie-flat baby carriers could be a safer option

In these situations a lie-flat baby carrier, sometimes known as a car bed, may be the safer option: See evidence here:


This is because:

  1. A five-point harness holds the baby securely in place.
  2. Additional inserts are available to make sure the baby fit well.
  3. These carriers have a strong shell and an energy-absorbing interior.
  4. Some models adapt to a sitting position when the infant reaches 10kg.

More info here: https://www.childcarseats.org.uk/types-of-seat/lie-flat-seats/

However, as mentioned previously; studies have indicated that the positioning of an infant in the car is not the sole issue and more investigation is needed to find the best way forward.

Studies have shown reduction in oxygenation in babies in lie flat and rear facing car seats.


i–Size rear-facing seats

These seats offer a lie-flat function. It is imperative to read the manufacturer’s guidelines since a selection of features should not be used when the seat is in the car.


Key advice for new parents of a low birth weight baby:

More investigation and studies are urgently needed & so neonatologists advise that the safest way to transport your baby in the car is as follows:

For at least the first month, babies should not remain in their car seats for longer than 30 minutes.

Journeys longer than 30 minutes should be broken up with regular breaks during which the baby spends time outside the vehicle.

This includes the journey home from the maternity hospital, which may be over 30 minutes long.


General advice for all parents when driving

It is advisable from a driver’s perspective to take a break at least every two hours of continuous driving.


Manufacturers recommend:

Each new premature baby or low-weight baby should be assessed on an individual basis and the parent should seek advice from specialists at the hospital.

Parents – especially first-time parents – should be aware that most rearward facing infant seats available, offer new born or premature baby inserts, to ensure that even the smallest infants are correctly fitted into the car seat with sufficient support for their spine, neck and head.


Research tells us to follow the manufacturers instructions

Statistics show that there has never been a case of a previously healthy infant dying in a car seat – when it was being used appropriately. Children who are correctly retrained in a child’s car seat run very slim risk of suffering from suffocation or strangulation. 2


Car seats should not be used as an option for sleeping, or as a high chair. The baby or child should always be strapped in when in their car seat and it should be placed on the floor when not in the car.

Fatalities have occurred when they car seat has not been used according to the manufacturer’s instructions and babies and children have died from falls, strangulation and suffocation as a result.


What is a safe period of time for babies to remain in car seats? And what about All-in-one systems?

With more information needed about infants experiencing reduced oxygen levels when sitting in their car seats for prolonged periods, surely there should be more research as to the safety of the all-in-one systems. These systems encourage parents to keep their babies in car seats as they seamlessly swap from car to buggy.


Advice from car seat manufacturers as to the safe duration for babies to remain in car seats, varies from 20 minutes to 2 hours.

There are no specific studies on the safe amount of time, but common sense suggests that it is sensible to offer regular breaks from the car seat.


Seek further advice

You can seek advice from child seat manufacturers about the length of time children should spend in their seat, or speak to a medical professional such as your GP who may be able to give specific advice. However, please be aware that they are only being guided by the most recent information and there is a desperate urgency for more research to establish clearer facts.


1 Arya et al. (2014) ‘Effect on Cardiorespiratory Function in Term and Preterm Infants Sitting in a Car Safety Seat, in a Simulated Moving Vehicle (Pilot Study)’, Arch Dis Child, 99(1): A1-A212.


2 Bamberg et al (2013) cited in Batra et al. (2015) ‘Hazards Associated with Sitting and Carrying Devices for Children Two Years and Younger’, Journal of Pediatrics


If you are interested in this topic, we suggest you read this article from our archive: Child Car Seats: information to help you make the safest choice


Written by Emma Hammett for First Aid for Life

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